Provider Demographics
NPI:1649402835
Name:MALLACE, ANTHONY (MS)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
Last Name:MALLACE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8320 NW 11TH COURT
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024
Mailing Address - Country:US
Mailing Address - Phone:954-432-8757
Mailing Address - Fax:
Practice Address - Street 1:2699 STIRLING ROAD
Practice Address - Street 2:SUITE B304
Practice Address - City:FT. LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312
Practice Address - Country:US
Practice Address - Phone:954-432-8757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH1149101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor